cc >> Thank you.
And it's a real privilege for me to be here.
I wanted to tell you before I accepted the invitation to come
to the University of Wisconsin, I had to reflect on what all my
Badger connections were. And actually, I have quite a
few. Two of my brothers have degrees
from the University of Wisconsin here in Madison.
And again, as I reflected on nurse leaders that have had a
significant impact in my development, have also had
connections to Wisconsin. Mary was my dissertation
advisor, and she has a degree from here.
And also Norma, a dean at the University of Pennsylvania had a
profound effect on my career. It's also a privilege to be here
at the Vivian Littlefield lectureship, because we did in
fact have an opportunity to work together when she was president
of the National Advisory Council for Nursing Education and
Practice, which oversees most of the money for the division
of nursing. I was absolutely young in my
career. She was very welcoming, and
certainly made an impact in the very areas that we're talking
about. Because it was under her
leadership, along with Marla Salmon that we commissioned a
report, of which I was chair at, to take a look at diversity in
the nursing workforce. That's still a publication, I
think, badly in need of updating.
But I think that was done in the '90s, sometime.
We've all lost track of time. So at any rate, it's a wonderful
privilege for me to be here. *I do bring you greetings from
Ann Arbor. ( laughter )
I have to tell you that usually I have a picture of our stadium,
the Big House, but we're not feeling too big
at the Big House these days. ( laughter )
So I thought this would be more appropriate.
*So this morning, what I'm going to talk about is health
disparities. And again, some challenges and
also some innovations. I want to start out by giving
some definitions of health disparities, talk about some
causes of disparities, talk about some of our challenges in
addressing disparities, and again, show you some exemplars
that I think give me hope in terms of us moving in the right
directions. *First of all, when we take a
look at health disparities, there are several terminologies
that get mixed up, from health inequities to health disparity,
to health inequalities. There are some very subtle
differences about these definitions that have
reflections in terms of policy and who we target as having
health disparities. Simply, a disparity
is a difference. It's an inequality.
It's when two quantities are not equal, as you can see here.
A health disparity is defined as a chain of events signified by a
difference in environment, access to, utilization of, and
quality of care, and also health status.
Or, a health outcome that deserves scrutiny.
*Currently, we have made policy decisions.
And this definition or who was considered the health disparity
population was defined by our government.
Specifically, here, the National Institute of Health says that
those that experience differences in health statuses
in access are racial and ethnic minorities, rural populations,
as well as socioeconomic status. Again, when we talk about
efforts to reduce disparities, these currently are the three
groups of populations that we're looking at targeting.
*Health and equality is based on observed differences and
reflects differences in opportunity, treatment or
status. For example, women live longer
than men. Migrant workers die younger than
stock brokers. Smokers are more likely to have
lung cancer than non-smokers. Poor mothers are more likely to
have lower-birthweight infants than non-poor women.
And undocumented workers encounter more barriers to
healthcare. These are facts.
These are simple differences. This is the health inequality.
*When we're talking about health inequities, though, we're
looking at differences in healthcare which are unnecessary
and unavoidable, but more importantly, unfair and unjust.
So given the example of health inequalities, we have to ask
ourselves, again, based on ethical judgments about these
differences, should migrant workers die younger than stock
brokers? Is it acceptable that smokers
have higher rates of lung cancer?
Is it acceptable that poor mothers have lower birthweight
infants? Should undocumented workers have
access to healthcare. I'm not sure we've come to an
agreement about all these. *We do know that all inequities
are inequalities. But are all inequalities
inequities? That's the question that we need
to answer. And these decisions are based on
considering, are all health disparities unfair?
Is it fair that someone is taller than you?
And which health disparities are fair?
Is there some level of disparity that we can work with, that we
consider acceptable? *When we make these ethical
judgments, we have to go back to look at, what are actually been
determinants of health disparities.
There are biological determinants.
There's health damaging behavior that's freely chosen, such as
perhaps cigarette smoking. There's health damaging
behavior, of which we engage in because there's limited choice.
For example, one of my colleagues told me about an
encounter she had with a poor woman around diabetes
management. My colleague, who's a nurse
practitioner, was saying, you know, you need to eat five a
day. You need to eat more fruits and
vegetables. And these are the types of foods
you need. She was telling her all this and
the woman said to her, "Honey, I'm going to give you the money
that I have to spend on groceries, and you tell me how
I'm supposed to do that." So again, the choices she
made, maybe not freely chosen, but because of limited choice.
There's also exposure to unhealthy conditions.
And again, inadequate access to and essential services for other
healthcare services. *I'm going to look at some, or
provide you an overview of some of these social determinants of
health, again, that play a big impact in terms of health.
We know from the big body of literature that social economic
status, regardless of how measured, by education, by
income, by wealth, predicts variations in health.
We also know that the link between SES and race are linked,
but they are distinct. Again, the best example of that
is when we take a look at infant mortality, and we take a look at
the differences in social economic status between low
birthweight infants in white and black populations.
At the poor level, the low SES status, disparities exist.
Yet, when African American women, who have higher incomes,
comparable to white women, their disparities or their rates of
low birthweight are as bad as white women at the lower
socioeconomic status. There's another dynamic that's
going on. Linked, but distinct.
*Education and income have been linked with infant and adult
mortality, acute and chronic infections and non-infectious
diseases. And we know that health
practices are patterned by SES. Again, persons with low SES are
less likely to reduce high risk behavior or initiate new
health-enhancing practices. Why is this?
Perhaps again, it's limited choices that are available.
*We also know, again, trying to figure out how these
environmental kinds of conditions really work to
associate themselves with mental health disparities for example,
or with cancer, or with some other diseases that we don't see
a clear link. But again, as we're looking at
different science approaches, we're seeing that again, chronic
environmental stress that's brought on by these conditions
may be an important pathway that we need to be taking a look at.
*There's another effect of socioeconomic status, and that's
community socioeconomic context. Again, when we're talking about
environmental hazards, we know lower SES communities often have
worse pollution. Lower SES communities often have
less healthy housing, work places, recreational areas,
consumer outlets, and greater exposures to toxins such as lead
paint, asbestos and infestation. *I was at the University of
Pennsylvania for a while, and I did work in the Latino
community. I went to North Philadelphia,
where there was a very high minority population,
predominantly a Puerto Rican population.
We did a lot of work in the schools.
The conditions were horrid, but what really struck me was that
we couldn't drink water. Forget about me, the kids
couldn't drink water from the drinking fountains because of
the lead pipes. *Another issue, and my
colleague, David Williams says this is the fundamental cause of
racial disparities is racial and ethnic residential segregation.
He said this is a fundamental cause of health disparities that
leads to highly segregated schools, which impacts quality
of education, severely restricts employment opportunities and
income levels of communities, and isolates people from role
models with stable employment and limits social network.
*Again, you can see by these graphs here, how segregated as a
society we are. And there's not been that much
difference between 1980 and 2000, between the segregation of
blacks and whites. And again, blacks are pretty
segregated from most of the other racial ethnic populations,
as well. So again, it gets to be
problematic, again, when we're looking at disparity issues.
*Another one is educational equality, and the fact that
U.S. Schools are structured that students routinely receive
dramatically unequal learning opportunities, based on the race
and social status is simply not recognized.
We were talking last night about the dropout rate.
I think in some Milwaukee schools, it's abotu 50%.
It's not just Milwaukee schools. It's Philadelphia schools.
It's Detroit schools. It's inner city schools.
Again, we know the critical links between education and
health, and education and future opportunity.
Again, this is an area that absolutely needs to be addressed
and considered. *So again, when we think about
health disparities, and we think about what determinants are, and
we think about the role of personal choice--
And this is said well by my colleague James Jackson at
Michigan, that says that if you live under very stressful
conditions, you have to work harder to maintain your mental
health. Sometimes the strategies you use
to cope become harmful in themselves.
You have to use what's available to you.
And the three resources that are most easily accessible to many
residents in African American neighborhoods: liquor stores,
fast food outlets and illegal subtances, are potentially
harmful. So again, to try and intervene
at an individual level, without considering context, becomes
problematic. *And our world continues to be
divided no longer by the formal, political and military walks,
but by a tragic faultline between those who can benefit
from those opportunities and those that seem cutoff from
them. Again, we're talking about
disparities worldwide, but our country is a microcosm of what
that fault and what that faultline is.
*One of the things that I'll bring to your attention is that
there is a PBS special that's coming out that's called,
"Unnatural Causes." And in there, a number of
noted scientists are going to be looking at, again, social
determinants in health, and racial ethnic disparities, and
talking about issues like infant mortality, cardiovascular
disease, and a number of different issues to take a look
at this context. Again, one of the areas that
people are looking at is that maybe we need to start reframing
our advice from, "Don't smoke. If you can, stop.
If you can't cut down. Eat a balanced meal,
the five a day." But rather to, "Don't be poor."
And if you can, stop. If you can't, try not to be poor
for too long, because it's detrimental to your health.
Live near a good supermarket and affordable fresh produce stores.
*In the city of Detroit and neighborhoods where I work,
there are no major grocery stores.
There are, again, fast food outlets, mom and pop stores.
So we know that it's easier to buy a bag of chips than it is to
buy a banana. *Again, another example.
Make sure you stay physically active and exercise at least
three times a week. And be safe on the roads.
Maybe that's not an issue here in Madison, where you're full of
parks. But again, it's problematic,
because people don't live in safe neighborhoods, where
there's good sidewalks, and again, where the environments
are safe. Again, relying on public
transportation, which in most major cities, is not adequate.
*I'm going to swith now to again talking about the emphasis on
racial and ethnic disparities, which we've indicated is a high
priority in our country, and certainly in policy areas.
I'll talk a little bit about those.
The main reason it's such an issue is because racial and
ethnic disparities are still persistant.
Most minority populations, African Americans, Latinos, and
some Asian populations have higher mortality in general, and
in age-specific conditions, as well as certain disease
conditions. And over the 50 years, these are
unchanged, and in many instances, getting worse.
*For example, we have not made a dent in the whole issue of
infant mortality among African American women.
The whole issue related to HIV/AIDS is absolutely
skyrocketing in African American and Latino populations.
Again, I think there are many incidences, both in cancer and
mental health, that have similar stories.
So we're not making a dent in that.
We can talk about it from it's a human rights, it's a humanity
piece. But again, these are important
people who contribute widely to our work force.
*I was driving in to the airport yesterday, and listening to the
whole debate of the Jena 6. There was an African American
caller who was talking about the situation.
And what he said was that over 70% of the prison population is
African American. And what he said was you can't
tell me that African American men are any more violent, are
predisposed to crime more than white men.
So there is an issue, again, in terms of what is equality,
again, what is justice and moving that forward.
So again, it brings light that there are many conditions that
play into these disparities. *We've had a number of policy
initiatives. The secretary's task force on
black and minority health was in 1985.
And again, that has been the spring board for a lot of
action, for more data, for more research.
It's a priority in terms of Healthy People 2000 and 2010,
which says we're working to eliminate these disparities in
healthcare. The National Institute for
Health, since the 1985 report, has made efforts to include
racial and ethnic groups in research.
Not only include them, but mandate that they be included.
The Department of Health and Human Services Office of
Minority Health, again, a number of different initiatives.
And the Institute of Medicine, with their landmark study on
unequal treatment that documented over and over, again,
the bias in healthcare against racial and ethnic populations.
*So again, we have a lot of policy initiatives, or let's say
we have a lot of nice policies written in paper.
There has been a shift in this administration in terms of
really, what the focus is and how we might be able to go about
that. So we have nice paper.
We have enough framework. But we don't have a lot of
action going in there, or at least not enough action that has
been able to make a measurable difference.
This is the quote from Healthy People 2010, again, which calls
for an elimination of health disparities among segments of
that population, again, by gender, race or ethnicity,
education or income, disability, geographic location or sexual
orientation. *So do you feel challenged
enough with trying to figure out how we're going to address this
particular issue? I'm going to bring a couple
more. *If we're going to be looking at
elimination of disparities, we need to be looking at
fundamental causes. And one of those would be the
elimination of discrimination. From Dorothy Height, who was a
civil rights maven says that, "Covert discrimination is the
problem. It's more difficult than overt.
Unless we acknowledge that racism exists, we will never
eliminate it. If people define racism only as
certain attitudes, then the solutions they will seek are
ways of changing these attitudes.
If racism is seen as pervasive, fundamental and systemic, then
the solutions sought will be different and deeper in
character." So maybe as a result of some
of the policy initiatives, maybe as a result of unequal
treatment, at least we have an awareness that racism plays.
Again, we can look at our attitudes and think about how we
might have encounters with patients at different levels,
and how we think about our care. *But what we're saying is this
is not enough. Many of the fundamental causes
of racism are institutional. They've been in place for so
many years that we don't even recognize why they came and what
kind of issues we're dealing with.
*My favorite example that I like to use is the GRE exams.
How many of you love to take GRE exams?
And what we know, what the science is behind the GRE exams
is that even the testers will acknowledge that they
discriminate against women and against minorities.
Those groups of folks are going to have lower GRE scores.
But yet, nursing schools hang onto to that as if it's a
fundamental predictor of success.
Yet, we have not done the work, either, to determine that in
itself will lead to success in graduate schools.
Some people are taking a look at that and some people have
eliminated that, or put that into consideration.
But again, that is a fundamental piece.
The whole issue of ACT and ACT scores came up, when?
After Brown v. The Board of Education.
And it was a way to keep black people out of colleges of higher
institutions. That's fundamental.
No one questions that. *A big issue, again, in trying
to deal with this is, again, do we really have a shared vision
of what's unfair and where it is that we need to go.
Again, part of that happens because our perceptions of
racial and ethnic inequities differ.
There are two huge news stories that, again, I think are raising
conversations about some of these inequities.
One of them is O.J. How many think O.J. did it
this time? ( laughter )
But more importantly, what's going on with the Jena 6?
And again, the whole discussion about did these six African
American students, was justice served in that particular area.
It's causing a lot of debate. I'm going to share with you,
again, some different perspectives that we have.
*This one has to do with Katrina.
This was a survey done that asked, "What would've been the
government's response if most of the victims had been white?"
The majority of blacks said that it absolutely would've been
faster. What whites said is that it
would've been the same. Perspectives on Katrina.
What were personal reactions to the disaster.
And again, you can see that Katrina has had more of an
impact on African Americans who felt depressed, felt angry and
had a close friend or relative that was impacted.
Again, not as signficant in terms of perceptions of white
persons. *Part of this comes from a
person's own experiences with racism and discrimination.
Again, a survey, have you ever had experience with racism in
healthcare, 35% of the African Americans, 36% of Latinos said
absolutely. And whites, 15%.
Never had an experience. *And I would ask you.
How many of you have ever had an experience where you felt you've
been treated unfairly? There's not a whole lot of hands
that have gone up. That's great for you.
But what this is saying is that realities are different.
This may not be your reality, but you have to acknowledge that
this certainly is other people's reality.
Perception is reality. *Another survey.
Do you feel that racial minorities have equal job
opportunities as whites? Again, what you see is that most
whites think absolutely, whereas African Americans and Hispanics
think less likely. This was a big debate, as we had
our proposal too, which eliminated minority or
affirmative action preferences in the state of Michigan, a huge
debate. Again, should students be
admitted by merit, or should race and ethnicity be
considered. Again, what we see is that
whites think it should be merit only, where again, blacks,
primarily and high among Latinos think that it should be a
consideration. Do you favor or oppose
affirmative programs for racial minorities?
Again, African Americans and Latinos favor that, as opposed
to the majority of the white population.
And again, part of it is determined when people say have
we made links, or have we made progress in eliminating
disparities or in moving these things forward.
Many people say we don't need it anymore, and that we needed it
at a particular time, but we don't need it anymore.
Again, different perceptions. *Here we take a look at issues
between immgrants and non-immigrants.
And again, huge debates. And again, some ugly things
going in this whole immigration sentiment, in terms of how it is
that we treat people, documented or undocumented from other
countries. Again, an immigrant strengthens
the U.S. because of hard work, immingrants are more hard
working than others. Again, higher percentage of
immigrants say yes, they are, as opposed to those who are
non-immigrant. Whereas, non-immigrant folk are
concerned that immigrants are taking jobs away, that the
government isn't tough on immigration, and that the
government should spend more to prevent illegal immigration.
So again, these are important challenges, the perceptions is
an important piece. *Other challenges, if you
haven't had enough, include the lack of diversity in the
healthcare work force, the lack of data and research,
and the limited science in health disparities.
Our profession, whether we're looking at nursing, medicine or
dentistry, do not reflect the composition of the population.
In nursing, I always say it's 2% Latinos.
It's been that way for 15 or 20 years.
And I don't think in my lifetime it's going to increase to be
more than that. It is more than just Latinos or
African Americans not wanting to be nurses.
There are other issues, again, that we need to take a look at.
Certainly, the diversity work force report that we did many
years ago highlights some of the issues, both in terms of
admission, in terms of recruitment, in terms of faculty
being prepared in cultural competence, in terms of the
diversity of the faculty, are all important systemic barriers
that need to be addressed. I think some of our nursing
colleagues think that well, gee, we're doing really better than
some of our professions. But it's, you know, bad is bad.
And nothing to be proud of here. *Another issue that I think
bears attention is the whole issue of what is our research
base for addressing health disparities.
I'm a researcher, so our course, it's an area that I'm concerned
about. Again, concerned about in terms
of how we look about that in terms of our links to practice.
A few years ago, two or three years ago, I edited a volume of
the Annual Review of Nursing Research.
And contributors were racial ethnic minority scientists.
And Sandra had a very important chapter there on cancer.
*Crosscuttingly, again, taking a look at all the chapters that
were done in cancer prevention and treatment, in terms of
health discrimination in our practice settings, nurses, and
looking at care of the elderly, and looking at care of children
with disabilities, this is what we found.
There were important subtantive areas that had not been
extensively studied. I think the one area, and
several things that came out in Sandra's chapter, and I hope
you're not going to be talking about that, I don't want to
steal your thunder. But important areas that had not
been studied was end of life care in racial and ethnic
populations. I think the whole issue of
prostate cancer in terms of treatment was another area that
had not been addressed. Lung cancer, although it's the
leading cancer killer, there are very few studies to be able to
do that. When I did one on children maybe
about ten years ago, I was astounded that there was maybe
two studies on sickle cell anemia, one of the most common
conditions faced by African American children.
So how is it that we're going to build practice when we have no
research base. It's not an issue only of
having-- *In this body of research, we
found that there were important areas that have not been
extensively studied. For example, nobody looked at
the issue of discrimination. Nobody looked at structural
barriers to healthcare. Given the study done by the
Institute of Medicine on equal treatment, there were very few
nursing studies that took a look at the issue of discrimination
or treatment by nurses in healthcare settings.
Most of the research that had been done had been done in
England. So why are we not taking a look
at that issue. Do we believe that nurses who
are all-loving, all-caring, don't discriminate.
No one has asked the question. But there's no way that we can
think, given all the stuff that's been around us, that
that's not going to affect interactions we have with
patients. Given that you're in a setting
where there is not diversity in your classroom, and maybe not in
your clinical experience. There isn't any reason to think
that you could have a shared perspective of what's going on
with that particular plan. *We found that there was limited
research on all racial and ethnic minority populations.
The majority of work had been done with African American.
There was less related to Latinos, and even less related
to certain Asian groups, and again, not in all areas.
For example, even the work done with Latinos, the majority of
the work was done with Mexican Americans, and not with Puerto
Ricans, who again, when you take a look at the gradient and
differences between populations, Puerto Ricans experience worse
health disparties than any other Latino subgroup.
*There's certainly a need for intervention studies and a need
for more expansive contacts. Again, given all the
determinants of disparities, we're limited, maybe by our
practice, maybe other reasons, but we're limited by taking--
We have a very limited view of environments, a very limited
view of persons. *One of the areas, my area of
research is HIV prevention. In my area, we know that there's
an increasing incidence of HIV among Latino youth.
But again, a few studies and a few intervention studies that
have been conducted with this group, there were no effective
interventions tested or developed with the population,
despite 25 years of the HIV/AIDS epidemic.
No evidence-based practice. No way to address cultural
issues related to Latinos. *There is now.
It's my curriculum. I'm happy to talk to you about
that. But again, we need more than
one. One is not enough.
We need to have one for youth. But there are still no
interventions for women. Again, incidences are increasing
among that population, so we need people.
We need researchers. We need people to take on that
particular issue. Again, these are certain
populations that, again, need to have interventions.
In talking, Sandra and I were having this discussion before.
You all have great challenges ahead of you in terms of the
research. We've addressed a lot of the
easy questions. I'm not going to say they were
easy, because they were very hard when we were doing them, as
well. But you have a base, then, of
which you can ask questions, that certainly are a lot more
difficult, and a lot more challenging, and require a
different perspective. We need for you to move it up a
notch, to move the science up a notch, to start looking at these
populations that are hard to reach.
As a reviewer, I get tired of hearing that we're going to do
this on a white population first, and once it's successful,
then we'll be able to apply it to different populations.
But it doesn't work that way. Different context.
Different reasons. Again, when you look at who is
in need, it's again, our monies are a little bit displaced, I
believe. *Our challenges are in bridging
the great divide, both in terms of practice and also in terms of
research. There's an historical mistrust
in communities, in racial ethnic communities, between
researchers, and also between institutions.
I remember when I was at one institution interviewing for a
position. I said I wanted to be able to
talk to some community members, because my research is
community-based. My colleague said, not a
problem, we're a very prestigious university.
We give a lot, the community loves us.
All we have to do is tell them we're from XYZ university and
the doors will be open to you. So I met with some community
leaders. I said, you know, I'm interested
in HIV prevention. Is this something that you're
interested in, something that you support?
They said to me, yes, you know, we're invested in you.
We want you to be successful. It's an important area.
We want you to work with us. They said, only one thing.
I said, okay. They said don't tell anybody
you're from XYZ university, or the doors will be closed to you.
( laughter ) So differences in perception.
*There's an incongruence of the methods of our research in terms
of how we work with communities. We need to study things.
We can't come up with an answer because we don't know enough
yet. When I started working on HIV,
or actually it was pregnancy prevention in the Michigan area,
I would start doing work, and they asked what they could do.
I said I don't know enough yet, you know, I'll let you know in
seven to ten years. They had no use for me.
And I could see that it's like I need to start moving and
shifting to look at joint intervention research.
While it may not be the total answer, and while it may be a
way to find the answer, again, it's progress in that particular
area. At least you're trying to do
something. Communities are facing these
issues right now. Much of our research happens in
hospital settings. We need to be adept at working
at more community settings and working in partnerships with
communities. *We love to control things.
I do experimental studies. I like to have lots of control
over different things, but that's not always possible in
clinical settings or community settings.
Again, we're trying to understand, it's important not
only for science, but it's also important for the diffusion that
we design interventions that communities are able to take
over. *I was at a CDC meeting, and we
had a meeting with researchers in communities looking at CDC's
agenda on their sexual reproductive programs.
And a community member said, you know, I wish researchers would
talk to us before they develop these interventions.
He said he wanted to use evidence-based interventions.
But the only evidence-based intervention that you have for
homeless is a 17-week session intervention, that's over an
hour long that requires a health professional to be able to do
that. He said that's not going to
work, and he could tell from the onset it wasn't going to work.
So again, if what we're creating isn't going to have utility to
the end users, we're missing great opportunities.
*Finally, there are a limited number researchers, black,
white, Latino, or others, who are willing to conduct research
with racial and ethnic minority populations.
So we have work to do to be able to work with you to help us to
address some of the issues. I'm not that old, but I am
worried about the next generation that's going to come
after me. And I want people to be engaged
in that type of research. I know many of you as students,
as faculty, are interested in that.
We would welcome you, I'm sure, to many of our programs of
research. We need people to take the
baton. *So before you get all
depressed, let me just tell you that there are some innovations
and I think some strategies that that I think are useful, and I
think some things to consider. First of all, it's important to
realize, if you didn't get this, that there are no quick fixes.
These issues have been rampant. We're not going to be able to
fix them with one research study, with one program of
research. There are no quick fixes.
This is going to take a concentrated effort of a number
of persons to be able to work on these.
*I think we need to be taking a look at population initiatives
versus behavior change only. And it means, I believe, that we
have to take a look at what it is that we're doing in our
research, and think about the policy implications, so it can
have a greater impact. We know for example that
seatbelts, water fluoridation and teenage driving, have
probably done a lot more to reduce car mortality and dental
caries than any "let me show you how to brush your teeth" type of
intervention. *We also need to be looking at
interconnections among conditions versus single
diseases and populations. Again, one area that I think
about is that whole issue of pregnancy prevention, HIV
prevention, and cervical cancer prevention, specifically among
youth. When you think about it, they
pregnant, they get HIV, and they get cervical cancer the same
way, sexual behavior. But people talk about these
things in silos, not recognizing that gee, maybe if I talk to,
you know, maybe the HPV vaccine is an opportunity for me to talk
to my child about sex and about HIV prevention and pregnancy
prevention. But these groups of folks aren't
talking across. So what you get would be so much
more powerful, for example, to lobby for comprehensive sex
education versus what it is that we currently have.
So again, being able to work across.
I mean, these are diseases that are related.
Cardiovascular disease and diabetes, for example, are also
related. And again, interventions are the
same, but people aren't talking and are looking at replicating.
So there has to be a better synergy.
*Finally, I also think we need to be taking a look at levels of
intervention. And I think this is what we're
talking about, how it's getting to be complex.
We have some interventions, and I'll say mine for example, HIV
prevention with Latinos, that gets at the general population
of HIV among Latinos. But then there are other
subpopulations that need more extenstive type interventions,
because that alone is not going to catch them.
So we have to, again, that's I think going up the next level
and targeting those populations that need additional resources.
*I believe the best health policy is good social policy
approaches. And that means education, that
means housing and neighborhoods, and that also means employment.
It means, I believe, for you all here and for you as faculty that
we have to move out of the classroom and that we have to
move out of the health settings and go into communities.
We need to see where our patients are coming from.
We need to understand what those realities are.
That's only going to improve our practice.
*As I said before, we need to look at the practice and policy
implications of our research. If what we're doing is not going
to improve policy, if it doesn't have real implications for
what's going on in practice setting, then I think we really
need to question why it is we're doing what it is that we're
doing. It's a great paper, but that's
about all it is. *I think promising approaches,
and again, we're getting a lot support from the NIH, is looking
at transdisciplinary work, looking at developing
sustainable partnerships, and looking at the development of
infrastructures. Many of the problems that we
discussed today, and that contribute to health
disparities, again, don't reside only with the nursing
and nursing science. We need sociologists.
We need demographers. We need educators, again, to be
able to work together, to be able to address these
situations. *I think again, in schools, in
areas that we're working with, we need to look at building
sustainable partnerships between communities and between
populations. There's no reason that each
individual faculty member has to find a population.
We do it among our schools, too. We're a school of public health,
and a school of social work, and a school of education.
It's the same community, and nobody knows that anybody is
there. They're working with the same
groups. Again, how much richer our
educational experience would be, how much richer the fruits of
our efforts would be if we were able to coalesce.
Again, the development of infrastructures, again, making
sure that faculty are rewarded, that students are rewarded for
doing the type of hard work that needs to be done.
*Just to mention, I was on a transdisciplinary initiative
looking at the issues of infant mortality.
It was a very interesting exercise in how it is that we
might be able to work together. It was difficult, a lot
of different times, because we certainly have different
perspectives and again, ways that we should go about
approaching particular efforts. We tried to do this in
combination or conjunction with communities, but we even had a
different perspective on who "community" was.
The physician who was PI of the group thought community meant
community providers. So when I talked about getting
input from community, that was his community.
When I said it needs to be pregnant women, he said, well,
they really can't help us define what our research studies should
be. And that was just contrary.
But the discussions were hot, and they were heated.
And I think that we were able to at least develop some good
science proposals. I think the most innovative one
that we had was between one of our researchers and also our
social worker, who was looking at food deprivation and food
access, and how that related to pre-term labor.
So we got some very creative things that went on.
I do believe that at the end of the day, we had some things to
teach our colleagues about approaches, about whatever.
*We had these discussions about people who say, well, the major
cause of disparities is racial segregation in neighborhoods.
And I'd say, well, I understand that, but I can't do anything
about that. I can move, but that's about the
only thing that I can do. So, you know, I understand that
a client encounter isn't going to solve the whole disparities
issue. But it's an opportunity for me.
It's an opportunity for nurses. It's an opportunity for
physicians. So let's figure out what we can
do in that encounter to be able to move forward.
But again, not easy questions. *I'm going to give you some
examplars. Again, of how we've been able to
at least move on this particular journey.
And the one that I have had the opportunity to work in, and have
certainly learned a great deal from, is our Detroit URC
Initiative, Urban Research Center.
It was established in 1995, so we've been together for a long
time. Initially brought together by
CDC funding. Once the funding ran out, we've
been very successful in getting NIH money, in getting other CDC
monies, and getting university monies, and getting private
foundations monies to support the work of again, these diverse
schools in their university, as well as two communities in
Detroit, one predominantly African American and one
primarily Latino. This is a community-based
participatory action research group that again, works well
with communities. *We have a set of guiding
principles. We say that our research is
conducted with mutual respect, recognizing the expertise that
each other brings to the table, and having open communication.
I will tell you, we have open and loud communication.
*Our principles, as we look at ways in which we can enhance the
capacity of everybody, not just the community-based
participants, but researchers as well, in the process.
We do, again, a lot of team building.
Our principle is that the community is involved as
appropriate in all phases of the research.
It's enlightening to, when I was talking about an intervention
study, and I was talking about a control group, I happen to have
an equal control group, and one of the community members raised
an issue about the control group.
I thought he was going to say, gee, how can you have a control
group when you know that this intervention is effective.
He was concerned that that control intervention that I had
was going to be too effective, and would diminish the results
of the effectiveness of the intervention.
So I though, oh, my gosh, how very wonderful.
*Again, we work at at striking collaborations among our schools
and among communities. And again, Detroit is very
segregated. So this process has allowed very
different partnerships, again, between these two communities in
Detroit. Again, we've looked at producing
and disseminating findings that again, reside not only in
journals, but again, through community forums.
*Our successes, very important. Most importantly, me as a
researcher, would say that we have good science.
That we have an infrastructure to reduce health disparities.
We have an infrastructure that supports education and research.
We have students involved in all aspects of our projects.
We certainly have had new partnerships among our members.
And the approaches have been interdisciplinary.
*But the last exemplar I'm going to mention to you is one that
I've been involved in for the past ten years.
And that is the National Coalition of Ethnic Minority
Nursing Associations. This is a group of all these
ethnic minority associations, the Black Nurses, Hispanic
Nurses, Asian Pacific Islander Nurses, Philipine Nurses
Association, and also the Native American Association, came
together and as we looked at our history and what it is that
we're doing, we said we can do a lot more with each other than we
can do in our separate silos. So we formed a coalition.
We've been in existence for ten years.
We're celebrating our anniversary on Capitol Hill.
*One of the tangible fruits of our labor is a $2.5 million
grant that we received from the National Institute for
General Medical Sciences to help prepare the pipeline of minority
nurse researchers. I would invite all the minority
nurses that are here, who are thinking about research as a
career, to visit our Web site, to talk to myself or Sandra,
who's been an important advisory member in this grant, to think
about coming to a conference that will be subsidized.
We will pay for your way to go. Next year it's going to be in
San Diego. The year after that in New
Mexico. But it's an incredible
opportunity to see other ethnic nurse scientists that are
working, and who are absolutely willing to support you on your
journey. *So in closing, I'll just leave
you with some nuggets of wisdom from the Motor City.
Coming together is a beginning. Keeping together is progress.
Working together is success. I'll look forward to successful
working relationships with you all.
Thank you very much.